Provider Demographics
NPI:1336272111
Name:ETTIE LEE YOUTH FAMILY SERVICES
Entity Type:Organization
Organization Name:ETTIE LEE YOUTH FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-503-3589
Mailing Address - Street 1:14101 VAI BROTHERS DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2172
Mailing Address - Country:US
Mailing Address - Phone:909-899-1435
Mailing Address - Fax:
Practice Address - Street 1:ETTIE LEE 5146 N. MAINE AVE.
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706
Practice Address - Country:US
Practice Address - Phone:909-620-2521
Practice Address - Fax:909-620-9793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA3813299101YA0400X
CA103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty